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Haglunds deformity- Arthrex Bio-corkscrew fixation and a postero-lateral approach

    Overview

    Learn the Haglunds deformity: Arthrex Bio-corkscrew fixation and a postero-lateral approach surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Haglunds deformity: Arthrex Bio-corkscrew fixation and a postero-lateral approach surgical procedure.
    There are three main varities of pathology effecting the area of the achilles tendon insertion and to which the description of a Haglunds’ deformity is commonly(and loosely) applied.
    Most often the pathology is one of degenerative change at achilles the insertion which may be associated intra-tendinous calcification. There may or may not be an element of anatomical prominence of the postero-lateral calcaneus associated. This tends to produce a fairly broad based swelling across the back of the heel. Usually the painful area is located laterally but it can on occasion be postero-medial.
    Less commonly the achilles tendon is normal and the issue is an anatomical variation of the postero-lateral corner of the calcaneus causing pressure when in shoe-wear.
    These cases should be imaged using cross sectional imaging to determine as far as can be done the location of both bony deformity and tendinopathy. This will assist in deciding upon the surgical approach to be taken. This will also on occasion show evidence of associated retro-calcaneal bursitis which should be intercurrently treated.
    The third variation is a calcaneus that is anatomically prominent posteriorly, laterally and also superiorly. This can cause direct impingement upon the deep(anterior) aspect of the Achilles in the retro-calcaneal area.
    These variations in pathology can be treated using the same surgical principles and with successful outcome expected in the majority of patients. The key is to identify the exact location and nature of the pathology causing symptoms.
    Non-operative treatment is somewhat less successful when adopted here than for problems with the main body of the achilles tendon.
    The 5.5mm Arthrex Bio-corkscrew is produced in a variety of materials including titanium, PLLA, PEEK, and biocomposite. The 5.5mm diameter version is ideally suited for this indication. It is used to re-anchor the achilles back to its insertion, this having been detached to debride the underlying calcaneus. In my practice I allow early protected weight-bearing in a post-operative boot after 2 weeks in the majority of cases if using the Arthrex Corkscrew, assuming at least half the insertion or so has not needed to be detached.

    Indications

    INDICATIONS
    -A true Haglunds deformity, with a non-degenerate tendon insertion. The posterior calcaneal bony prominence may be either purely lateral or supero-lateral. This version of the condition is commonly know as “pump bumps”, a pump being a low-cut shoe and a bump being a bump.
    -Insertional Achilles tendinosis, which may have associated intra-tendinous calcification
    SYMPTOMS & ASSESSMENT
    The “true” Haglunds deformity is a variant of the normal postero-lateral calcaneal anatomy with a prominent edge to the calcaneus that is at risk of rubbing on the heel counter of a shoe. Once this rubbing starts, and some superficial soft tissue thickening develops, the area self-evidently becomes more prominent and further rubbing is more likely .This type of presentation is classically in the younger patient . The inserting tendon is normal. Swelling is limited to the postero-lateral aspect of the Calcaneus and it would be unusual to have more generalised posterior calcaneal tenderness or tenderness of the distal Achilles tendon before it attaches (see the clinical pictures at the end of the operative technique). Symptoms are exclusively when pressure is directly on the heel (such as in shoes or occasionally in bed).
    More common is insertional tendinosis of the Achilles. There may (or may not) be a variation in the shape of the calcaneus and the prominence here is often much more diffuse and greater. Here pain is not infrequently also when out of shoes and activity related. On examination the swelling and tenderness is much often more diffuse and may extend into the distal non-insertional Achilles tendon. The exact areas of tenderness should be noted as the distal tendon prior to insertion may require a degree of debridement. It is also worth examining the retro-calcaneal area, sitting immediately anterior to the distal tendon and inferiorly bordered by the most superior and distal part of the calcaneus. This can be another source of alternate (or not infrequently associated) pain.
    INVESTIGATION
    Imaging is required prior to operative intervention. This is to identify the extent and location of pathological changes within the Achilles and also the bony pathology. It should be appreciated in imaging the bone that though both a superior calcaneal prominence and intra-tendinous calcification can both be easily seen a pure postero-lateral “pump-bump” may be better visually appreciated than imaged.
    Plain X-Ray: A lateral X-Ray may show larger areas of intra-tendinous calcification. It may also have a role in identifying some bony Haglunds deformities where the issue is one of a posterior and superior prominence of the calcaneus. If however the deformity is a purely lateral ridge it will not be detected by plain X-Ray.
    MRI: A better investigation is an MRI which will assess the 3D nature of the calcaneus as well as the state of the Achilles tendon. In particular it is of use in determining how much Achilles( especially how far medially ) will likely need to be elevated off the bone to clear and debride intra-tendinous calcification. Inflammation in the retro-Calcaneal area can also be diagnosed.
    Ultrasound :(plus or minus injection therapies) have little role in this area unless there is a well defined and inflammed retro-calcaneal bursa
    CONSERVATIVE MANAGEMENT
    -Avoidance of aggravating shoe-wear
    -In very flat feet a small medial arch orthotic may make the postero-lateral heel less prominent in shoes
    -For insertional tendinosis a short course of physiotherapy to the tendon itself may possibly help (but is not likely to be as definitive as it would be with problems of the tendon body). This may include shock-wave therapy (see results section).
    SURGICAL ALTERNATIVES.
    –A direct posterior approach: The Achilles insertion can be accessed by a trans-tendinous approach and the same objectives achieved
    –Realigning Calcaneal osteotomy: With a Haglunds deformity that has a posterior and superior bony prominence the postero-lateral calcaneus can be angled away from impinging on the Achilles by a closing wedge osteotomy through the superior & posterior aspect of the Calcaneus (Zadiks operation).
    –Minimally invasive technique: With a Haglunds deformity that has a posterior and superior bony prominence the postero-lateral calcaneus can be treated by a minimally invasive burr technique.
    –Medial approach: On occasion a medial approach to the deformity, skirting the anterior border of the Achilles medially, is more appropriate. This is determined by the location of symptoms (which can be predominantly medial) if this is where the main intra-tendinous pathology lies.
    CONTRAINDICATIONS
    No specific ones. Poor compliance , poor vascularity and conditions or medications that compromise wound healing are relative ones that will require optimisation.

    Setup

    GA or Regional Anaesthetic and Popliteal block for post operative pain relief.
    The incision used most sensibly is postero-lateral & just skirting anterior to the tendon
    One or two side supports should be placed on the non-operated side at thigh and trunk level whilst several sandbags are placed under the operated buttock , thus turning the operated leg into internal rotation
    The further addition of rolled up sterile towels behind the calf allow extra degrees of rotation.
    Thigh tourniquet to be used and Flowtron calf-pump on non-operated calf.
    Prophylactic antibiotics and LMWHeparin peri-operatively & post-operatively
    Bipolar diathermy

    Operation

    On the right the characteristic appearance of a classical “pump bump”, a bony variation of normal in terms of the calcaneal anatomy.

    The right side in this case is clearly a different thing with diffuse thickening and swelling of the whole Achilles insertion seen with widespread insertional degenerative change.

    A particularly large and established area of intra-tendinous calcification (1).

    For a Haglunds deformity the incision is over this postero-lateral prominence , just skirting the lateral margin of the Achilles tendon(2). The incision does not need to extend distally too far into the soft tissue of the heel pad
    If Insertional tendonosis without an associated Haglunds is being dealt with then a medial approach can be considered if preferred. A medial approach may be required if the main pathological change is within the medial aspect of the tendon insertion.

    Blunt scissors dissection should be used through the fat layer as this may contain fine cutaneous nerve branches( here to the left of the wound) which can be easily avoided if seen. The risk is in producing a painful scar neuroma if divided.
    Once through the fat there is no clear anatomical plane separating the Achilles from the deep fascia. This needs to be created surgically (see next surgical step).
    The Achilles should also be inspected at this stage, both the insertion and the lower portion of the body of the tendon. On occasion the para-tenon will be thickened and this should be sharp-dissected off the tendon.
    If dealing with insertional tendinosis then there may also be a requirement to place longitudinal incisions into the tendon substance, to stimulate a healing response in the tendon.
    The skin edges should not be unduly undermined. Wound healing and breakdown in this area is an issue.

    The plane between the lateral edge of the Achilles tendon (2) and the deep fascia(3) should be identified and then opened with knife dissection. This will bring one onto the the postero-lateral calcaneus(1). There is no actual plane, one is simply using the lateral edge of the Achilles as a marker for what line to dissect inferiorly along.
    The anterior deep fascial layer should be sharp dissected as a single layer off the calcaneus in a superior direction.
    It may well overlie part of the Haglunds ridge of bone and is also a very useful thick layer to anchor the Achilles back to during closure.
    The retro-calcaneal area should also be inspected (the space between the deep, or anterior, surface of the Achilles and postero-superior calcaneus), lying between points 2 & 3. On occasion an inflammatory bursa is here that should be excised. This may have been identified on the pre-operative MRI and upon examination.
    If the calcaneus is prominent superiorly this highest point of the bone can be removed to the same level as the rest of the superior aspect of the Calcaneus using an osteotome. All bone resection should be left rounded and smooth which usually requires finishing off with a bone nibbler.
    The lower Achilles should also be debrided at this stage if indicated which would require a more proximal extension of the wound shown here. If there are areas of neo-vascularisation adherent to the anterior aspect of the achilles these should also be detached.

    A deep sub-periosteal plane is then developed in a posterior direction, elevating the achilles from its insertion. A proportion of the deep attachment of the Achilles needs to be released (1) to expose any true Haglunds deformity(2). This may be purely postero-lateral or may have a superior projection also . If there is also a large area of calcification within the insertion(as with severe tendinosis) the Achilles will need to be sharp dissected off this in addition. It is important to study the saggital and axial MRI views in particular to appreciate pre-operatively how much of the Achilles may need to be elevated from its insertion. On occasion this can be really very far medially.
    One should also be aware that on occasion the calcification may be mainly intra-tendinous and by carefully elevating the tendon off its attachment the calcification will remain within the soft tissue. It is sensible therefore to also palpate the tendon whilst it is being detached in case intra-tendinous excision is required.
    The McDonalds is a helpful instrument to place the Achilles under tension whilst dissecting it off the bone.
    Care should be taken during this step not to completely detach the Achilles. Ideally no more than 50% of the insertion will be detached but it can easily go to this if exposing a large area of intra-tendinous calcification.
    At this level of remaining attachment I will allow the patient to early weight bear in an Aircast boot (after 2 weeks). Much more than this and non-weight bearing for first 4 weeks will be required in a plaster cast.

    Once the extent of the deformity is defined (2) it can be removed with a Hibs osteotome(1).
    Here a prominent bone ridge is being removed which is straightforward to identify.
    Intra-tendinous calcification will sit deeper within the tendon insertion and will not be so immediately obvious in terms of its location. A more extensive release of the Achilles off the bone will be required and reference continually made to the lateral & axial MRI images. Once intra-tendinous calcification is identified dissect very closely to it to remove attached tendon. Always be mindful of how much Achilles insertion is remaining attached to the Calcaneus and aim to leave 50% of the insertion unreleased.
    Once the calcification/bone is revealed remove using a small & sharp Hibs osteotome.
    It should also be routine to inspect the most posterior and superior point of the calcaneus , where it abuts the Achilles but is proximal to the attachment. If this is prominent this “apex” should also be removed. This will not have Achilles insertion fibres attached to it. There may also be an inflamed “retro-Calcaneal” bursa sitting between the Achilles tendon and such a bony prominence. This soft tissue should also be excised.

    The Haglunds deformity being removed. The Achilles protected with a McDonalds.
    It is key to ensure that no bony ridge or prominence is left and this bone resection needs a fair bit of smoothing back with angled cuts of the osteotome or bone nibblers also.

    The lateral calcaneum taken back to cancellous bone(1).
    The reflected insertional fibres of the Achilles(2).
    Before reattaching the tendon ensure that the deep surface of the tendon has been thoroughly inspected and debrided if required.
    The process of debridement may require only limited longitudinal incisions into areas of tendinosis. Centrally placed cysts may be excised and resultant cavity closed with an absorbable suture. One should be mindful to leave adequate intact tendon to allow good bites of the suture into it which will be used to reattach the tendon.
    Ensure also that all areas of bony prominence have been chamfered flat before the tendon is reattached.

    The tendon being reattached using an Arthrex Bio corkscrew suture anchor. An initial track in made with the spiked probe(2). This should be in thick bone (1) ,well away from both the superior edge of the calcaneum(3) as well as the subtalar joint(though this is fairly far anterior in terms of the deep exposure).
    Adequate thickness/depth of bone is required to house the anchor so it should not be placed too superiorly or posteriorly and close to the margin of the bone. The position used to attach could also be directly posterior on the Calcaneus . It is important to try and place the anchor fairly central relative to the amount of tendon to be reattached.
    The “pull-out” strength of the implant is increased by placing the implant at 90 degrees to the line of pull of the Achilles tendon as seen here .

    The initial Arthrex guide needs to be inserted up to the marked line.
    In dense bone this may need to be tapped in , or may just provide a small cortical breach adequate enough to get the tap started.

    The thread for the Bio-corkscrew implant needs to be cut using the tap(3) ,again up to the line on the tap (or very slightly deeper)

    The loaded Bio-Corkscrew anchor(1) is screwed into place(2) , up to the marked line on the metal introducer.
    It is important to take note of the resistance encountered when screwing the implant in . Occasionally no more movement may be possible prior to the line being well enough implanted. Further attempts at tightening in this scenario may lead to the implant breaking. Avoid this & re-tap the thread.
    Consideration can be given to using a second suture anchor if a fair amount of the achilles insertion has required reflection from the bone. Given the Bio-corkscrew is a 5.5 mm implant there is not always easy space for two. Fixation with a single implant (and careful periosteal closure) can be adequate in some cases.

    The implant appropriately seated (1) with two non-absorbable fibrewire sutures attached to each Bio-corckscrew.
    The implants “pull out” strength should be manually tested to ensure adequate fixation has been achieved. The tendon is most effectively reattached if both ends of each suture are sewn through the Achilles and then tied on the superficial surface of the tendon.
    Only good “bites” of tendon tissue should be accepted as anchor points . The sutures should be placed to give a wide compressive effect.

    The reflected achilles (1) about to be reattached with the two fibrewire sutures(2). Time should be taken to ensure that the knots are not prominent. It helps to leave the suture ends very slightly longer so they will sit flatter rather than stand proud.
    An over-sew of the free edge of the Achilles may be required to the neighbouring calcaneal periosteum with an absorbable suture if the tendon insertion is somewhat proud after re-attachment.
    It is not bad practice anyway to use this thick periosteal layer as another anchor point for the reflected Achilles, using a heavy gauge absorbable suture.
    Skin closure is with absorbable suture material and sub-cuticular skin closure.

    Diffuse calcification sitting very much within the soft tissue insertion of the Achilles but not the same density as the calcaneal bone and therefore not likely directly attached to the calcaneus but to be found in the tendon.

    Additional features seen here are both some subtle bone oedema in the superior aspect of the calcaneus and also inflammatory tissue in the retro-calcaneal space.

    Post Operative

    The first two weeks are spent in a lightweight cast, touch weight bearing only.
    After two weeks compliant patients may be transferred into a long post-operative boot and commence progressive weight bearing slowly & carefully using crutches.
    Usually by the end of 4 weeks post op it is comfortable to weight-bear just in the boot without the need for crutches.
    From 5 weeks commence weight-bearing physiotherapy rehab (strength & balance) and non-weight bear strengthening and range of motion excercises.
    Static bike may be possible from 5 weeks
    Cross-training may be possible 7 weeks
    Light Full weight bearing jog on treadmill may be possible from 10 weeks
    (sooner on Alter-G treadmill or in pool)
    A return to full and unrestricted sporting activity is very patient dependent but unlikely sooner than 4 months post-operatively( see published results)
    Of upmost importance through-out the post-operative period is that the wound is looked after. Wound infection and small areas of breakdown occur easily in a freshly healed wound that is allowed to rub on socks/shoewear.
    Any exudate from the wound which is allowed prolonged contact with the wound will further excacerbate any skin breakdown. Dressing changes may therefore need to be frequent if such a complication ensues.
    Once out of cast I advise another month of daytime dressings when in shoes and also nocturnal dressings whilst any of the wound remains unhealed
    Showering & bathing is from when out of cast

    Recommended Reading

    Eccentric loading compared with shock wave treatment for chronic insertional achilles tendinopathy.
    J Bone Joint Surg. 2008.90-A.52-61.
    J.D.Rompe, J.Furia, N Maffuli.
    50 patients treated with either Shock wave or eccentric loading program.
    1/3 had success with the loading program versus 2/3 with the shock wave treatment.
    Haglund’s Syndrome: Disappointing results following surgery-A clinical and radiographic analysis .
    Schneider W, Neihus W, Knhar K.
    Foot & Ankle International January 2000 vol. 21 no. 1 26-30
    49 cases who underwent a resection of the postero-superior portion of the calcaneus with a mean follow-up of 4 years. The clinical results were complete relief in only 34 procedures. This equates to 70% of the cohort which I think is quite impressive given the “bluntness” of the operation in targeting specific symptoms. 7 patients were worse. Rehabilitation took an average of 6 months .
    Calcific insertional achilles tendinopathy :Reattachment with bone anchors.
    Am J sports Med.2004 .32(1):174-82
    Maffuli N,Tesata V, Capasso G,Sullo A.
    21 patients treated operatively as per the technique described in the Atlas. Outcome was graded excellent or good in 2/3 of cases . 5 patients unable to return to previous level of sport .
    Treatment of insertional achilles pathology with dorsal wedge calcaneal osteotomy in athletes
    Foot & Ankle Int 2016. Dec.
    Georgiannos D, Lampridis V, Vasiliadis A, Bisbinas I.
    52 patients who had failed conservative management were followed up for a minimum of 3 years following a dorsal closing wedge calcaneal osteotomy performed through the superior aspect of the Calcaneus. No direct surgery to the Achilles itself. The results were rated as excellent in 73%. The time on average required to return to sport is noted as 21 weeks.
    Operative treatment of insertional achilles tendinopathy through a transtendinous approach
    Foot & Ankle International March 2016 vol. 37 no. 3 288-293
    Ettinger S et al
    Forty patients (failed conservative treatment) operated upon using a trans-tendinous approach, debridement of pathological tissues and reattachment of Achilles with suture anchors. Over 80% had either good or excellent results.

    Reference

    • orthoracle.com

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